Comparison of accidental pediatric scald burns in a tertiary care center: hot cauldron burns versus accidental spill burns

Introduction

Scald burns are the most common types of burn injuries in children throughout the world.^1,2 These injuries are the leading causes of morbidity and mortality in the pediatric population.^3,4 They have long-term physical, psychological and economic impacts on the patients and their families. The majority of scald injuries occur at home and most of them are accidental and preventable.^5–7

Scalds result from exposure to hot liquids or steam. They occur mainly by two mechanisms: (i) spill and (ii) immersion burns.^8–10 Accidental spill burns are due to spillage of hot liquid such as boiling water, tea, milk, oil, soup, etc. These burns usually happen if a child gets in the way of an adult carrying hot fluids or accidentally play with the utensils filled with hot liquid and spill over their body. Immersion burns take place when children fall or put their hands/feet into a vessel containing hot liquid such as bathtub, tea/coffee pots, hot cauldrons, etc.^3,6,11–14 Past studies have shown that the patterns of these two scalds differ widely for different age groups, gender, and body parts involved, with differences in hospital stay and outcomes secondary to extent of burns.^6,15–17

The study of different types of scalds can help to control or reduce the predisposing factors and ultimately help in formulating plans and strategies for prevention. This study aimed to compare accidental spill and immersion (hot cauldron) scald burns in different aspects in a tertiary care center. Moreover, the factors affecting mortality were also studied.

Methods

Results

A total of 120 pediatric patients with scald burns were admitted during the two-year period. Out of them, 12 were excluded from our study due to their incomplete records. Finally, 108 cases were analyzed.²³ Demographic and clinical characteristics of the patients are shown in Table 1. The median age of the patients was 2.8 (IQR = 1.6-4.0) years. In total, 61 (56.5%) of them were male and 47 (43.5%) were female. The majority of the burn injuries occurred in the kitchen (57.4%) and most of the patients were from the Low mountain region (60.2%) of Nepal.

Overall, 43 (39.8%) had HCB and 65 (60.2%) had ASB. There was no significant difference in age, gender, place of burns, and pre-hospital intravenous fluid use in the two groups of scald patients. Baux score was higher in HCB (17.5, IQR = 14.0-27.0) but the median body surface area of burns was equal (15%) in both the groups. In total, 13 cases (12.0%) had an infection at presentation, which was higher in HCB (53.8%) than in ASB (46.2%). Neither of them were statistically significant.

The most commonly involved body parts were lower extremities (55.6%) followed by upper extremities (49.1%) and hands (40.7%). Of all the lower extremities burns, 36 (60.0%) were from ASB, and 24 (40.0%) were from HCB. None of these were statistically significant.

Tangential excision was performed in 52 (48.1%) patients, of which 34 (65.4%) and 18 (34.6%) belonged to ASB and HCB groups, respectively. Cases requiring the second excision (7.4%) were equally distributed in both groups (50.0%). Only two patients required flap and amputation and they were from the HCB group.

Overall mortality was 16 (14.8%). Out of total deaths, 12 (75%) were from HCB and four (25%) from the ASB group. This was statistically significant (p = 0.002). Requirement of in-hospital blood transfusion was significantly higher (p = 0.030) in HCB (57.1%) than ASB cases (42.9%). The median duration of hospital stay in both groups was nine days (IQR in HCB: 5.0-13.0, ASB: 3.0-14.0).

A significant association was seen between the dependent variable mortality and type of scalds (p = 0.002), place where burn injury took place (p = 0.010), and involvement of body parts like back (p = 0.015), buttock (0.001), perineum (p = 0.026) and lower extremities (0.005) (Table 2).

Discussion

In our study, HCB and ASB accounted for 39.8% and 60.2% of total cases respectively. Although there are numeric differences across the two groups in terms of demographic and clinical profile, statistical significance exists in mortality and in-hospital blood transfusion only. Overall mortality was 16 (14.8%), out of which 12 (75%) were from HCB and 4 (25%) from the ASB group. Blood transfusion was required more in HCB cases (57.1%) than in ASB cases (42.9%). Mortality was higher in male gender (16.4%), burns outside the house (40.0%), body parts involving head and neck (18.2%), chest (15.0%), back (29.0%), abdomen (22.2%), buttocks (34.5%), perineum (44.4%), lower extremities (23.3%) and those who underwent escharotomy (16.7%) and necrosectomy (50.0%). Out of these, burns outside house (p = 0.010), involvement of buttocks (p = 0.001), back (p = 0.015), perineum (p = 0.026) and lower extremities (p = 0.005) were statistically significant.

A study in India¹⁸ reported the mortality in pediatric scald burns to be 3.1% which is lower compared to our number (14.8%). The plausible explanation for these differences is the difference in the site of study, sample size, and duration of the study. Another reason could be because our center is a national referral center for burns, so it is likely that more complicated and extensive cases are being referred here. Another study in Kashmir, India¹⁹ showed mortality from scalds to be 10.7% which is comparable to our findings. The most common place of burn event in our study was a kitchen (57.4%) which is comparable to a study (64.7%) done by Riedlinger DI et al. Similarly, grafting was done in 41.2% of patients which also corresponds to our study (46.3%).⁵ Another study⁶ depicted the incidence of accidental immersion and spill burns as 5.4% and 81.4%, respectively, which differs from our findings where immersion (hot cauldron) and spill burns comprise 39.8% and 60.2%, respectively. Similarly, a Turkish study³ showed that the most frequent cause of burn was scalding from spillage of hot water (59.7%) followed by bath scalding (i.e. immersion injury) accounting for 26% of cases. This is in line with the percentage of spill burns in our case. Likewise, in Japan, immersion burn (59.3%) was reported to be higher than spill burns (40.7%).¹⁶ This could be due to the provision of the bathtub in developed countries like Japan where there is a high chance of children climbing up and falling into bathtubs.

The most commonly involved body parts were lower limbs (55.6%) and upper limbs (49.1%) in our study. This finding contradicts a study by Drago DA et al,⁶ where the upper torso (25.3%) and upper limbs (24.1%) were maximally involved. A Japanese study¹⁶ revealed that the most common sites of immersion injury were trunk and legs (80%) followed by arms, and those of spill burns were trunk (91.7%) followed by head/neck and arms. In our case, the most common body parts involved were lower followed by upper extremities. The same study showed the average body surface area of scald as 11.3% which is slightly lower than ours (15.0%). Immersion-related burns were more likely to be located on the lower half of the body involving buttocks, thighs, legs, and feet in a French study.¹⁷ Another also found out that most scalds occurred on the upper limbs.²⁰ These discrepancies could be due to different sample sizes and sites of study. The mean total body surface area reported in a study from Arizona²¹ was 8.0% which is much lower than ours (15.0%). The difference could be due to our center being a referral center where complicated burn cases are being referred from all over the country. However, the mean length of hospital stay in this study²¹ (8 days) is similar to our study (9 days).

In a study from Ontario,¹⁵ Children with spill burns had a shorter average length of hospital stay (10.8 days) compared to those involved in bathtub immersion burns (18.3 days). In our study, the median duration of hospital stay was equal in both the groups of scalds (nine days) though it was not statistically significant. Likewise, in the same study, the mean age in both scald groups was 1.8 years whereas, in our setting, the median age in HCB and ASB were 3.0 and 2.5 years, respectively. A study from Beijing²² showed that the scald burns most commonly occurred in the kitchen which supports our result.

There are some limitations of this study that need to be mentioned. The number of cases was lower than expected because of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Lack of complete data also excluded a significant portion of cases from the study. The data also fails to analyze the economic status of children which could make them susceptible not only to a certain type of scald burn but also limits the access to first aid and primary care, hence affecting the outcome. Moreover, this is a single-center study over a short period of time so, the results may not be applicable to the whole country. For that purpose, multi-center studies conducted over a longer duration are recommended.

Conclusions

ASB was more common in our setting. The mortality was higher in HCB group. These were more likely to require an in-hospital blood transfusion compared to patients with ASB. There were no other significant differences between these two groups. The risk of mortality was significantly higher in burn events occurring outside, and those involving the back, buttocks, perineum, and lower extremities. So, special focus should be given to these factors during management.

Data availability

Figshare: Comparison of Accidental Pediatric Scald Burns in a Tertiary Care Center: Hot Cauldron Burns versus Accidental Spill Burns.sav. http://doi.org/10.6084/m9.figshare.16583501.²³

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).